17C-254 (3) �SMPT
O O
Grxty of Xort4antpton r
� � ,�lassachusctfe - ',
DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l:is/her construction sups:."sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
w (<
�1•Tfl3 Llf \1C7�" �jcil]]�Jf[11I
6 rS?t 1 S RCll ti 5 r 115
m DEPlu I Nrr 01' EUILDII�G INSPECTIONS
212 Main Street ' Municipal Building
?Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A i F A IT
\vlf a a principal place of busiresslre:; deticc
q13%5—,f x/-�7
�SLTC:(ICrt:iS'aCih p)
do hereby Ccr—df-'• Una c!" flit' pains aii7 pCil lit S of perulrl, lhi!::
I alit an enaployer p7oviding the iollo viml :Ort_cr`S CotllpciM[IOD COVCI::L',C ;Or Inn
eltlployees worEng on t?Iis job:
(LnsuranG Goclram) ('P 0;;
t=ira on D2te)
!r Sole proprietor era-( con��or ilonleo.�ner (CLCIe Oct) and ha',e lured
C r is el(We l +�0CkP12S C.01-peIlSi =0i1
( "T=C of Conurn ctor) �IISL'_..r1C l OIP.^`::'t'Pollc-t c
NLLnb )
(Name of ConLrac,,or) 0 `:p 'a!ion Date)
("Name of Contractor) x . ri-.n7, DaI,)
-^(Name of Contractor) —- (Ins rand Color Y:}'!Policy Nu.mb�lr) (H;:ri-:.io Date)
l
1 <LITl <: UlC plU-()I1CC<)i tiil'1 have no fol ale.
In to horlle C)1';?ler i3Ci:C1"1I11r1 1�f it. �',_... iiiY� ll.
NO-IT:plc:sc be at.-a:c tha:xLi.]c!x<:�o,:r s :.o c p!cr;r— a> �_•:tea ar:: a cr:c;:n r cl!ir.
not Mcce th_a throo units in t i ich .hc o,
ca ployc3 u.>ue thr tvca:Tx cc r•—sari-n ,r (GL.!5w !{Sl' a+:r ixz'ia: y a hot t o«ncs`cr e lira c<p:r.u:
legal tiaras of an a:.iployx ucx'.cr the We kCei
I
f u.ndc_--hand thi:a cvay of tha- ctatc::a-:a:,y bo fo,—n dS l to tin IYtxirv-xrn:.of IndsuriJ Attii&m:y claw of'.::—r�_c for tl�
covtr�&se veriEc--i oo and thsi failure 25A of MC-L.152 ew lc--d to the 1"ITosifion
comuling of a rur_of up to S 1-300.00 and'x ir.:iu.xn;c.!of to e:-.j civil,,values in d,fcmn of a S!r,, F'm Oti=t l e
L•MCCSIN0wedtyig�.in:r
_ J=cr ck3%zvn�tsl uic oily l
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_::�,•r.-, Si�nrtturc ttI'I; cn.,c�JI'�rrit trr:. �
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A
SECTjON 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
e on tract Not Applicable ❑
Com an N �ej Regi-sTration Number
L/ A)
Address6' �r - Expirat on Date C�
tv�s�e-A-S AAA 016 : Telephone CX
SECT
ER
ION 10 WORKS' COMPENSATION INSURANCE;-AFFIDAVIT(M G.-L. c-. 152, §;25C(6.))
f:r, ..
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance oft wilding permit.
Signed Affidavit Attached Yes....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeo,.vner" shall submit to the Building Official, on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of..._
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECII!ON: - D S. iTo �FPROPOSEDEIYORK ch ckafl a livable
a r a r axon Mr w� i
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes_e� _No Adding new bedroom Yes � No
Attached Narrative D Renovating unfinished basement Yes /"No
Plans Attached Roll❑• Sheet❑
6a' MR UWMUMWWU 'dition toTexisting housing co—fir Elie foll.ov'�i-w:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within.100 ft. of wetlands? Yes No, Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECT ON T �OINNER'yJ 1MORIZATION TO BE COMPLETED WHEN
OWNERS
n_AGENT�OR!CONTRACTOR APPLIES FOR BUILDING PERtVI1T
.. .. ._F
I, f v as Owner of the subject property
h eby thori e ��l 1 �. > <— ` to act on
be If, in a tterjs�r'el tiv to rk authorized by this building permit applications
1Z V's t art
Signature of Owner Date
as Owner'Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and ef.
Signed under the pains and penalties of perjury.
Print N
Signature of Owner gent Date
Section 4. `
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
I
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
i
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
i
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook body of water or wetlands? NO -, DONT KNOW
YES
IF YES,has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: /
C. Do any signs exist on the property? YES NO
IF YES, describe size,type and location:
D. Are the any proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
r" AA
Cl of Northampton
— ing Department
l5 l� Main Street
Room 100 -
1I AUG 1 N pton, MA 01060
' 6
ph 2004 one 41 -58 1240 Fax 413-587-1272
iwrU
APPli &nOw ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
w Tlhis sect-on"#aeompteted bT office
1.1 Properly Address:
i ` 1 sh'�tik• f� t�"s � Flea'` c-n,.= r �,� �� �?,•. �','.,a
1 v
0 Q�E i'1 c e C`l A l QS C Z- "Zone E4 y, Overtax D>ISd act
f
SECTION 2- PItOPERTY-6WNERSHIP/AUTHORIZED AGENT
2. wne of Record: p tt,, l /
t Mo Iw at 1 X 1 T SlivuE QoAb - VErA i F- +t- 4;L
M me(Print) CurrenV Mailing_Add
re
Q I,
V-4;1 Telephone
Signature
2.2 Authorized Agent:
�C> �y&)KJ AeD t e cis; tit�l yto 3
Name(PriM Current Mailing Address:
Signature Telephone
SECTION.3-ESTIMATED CONSTRUCTION`'COSTS
Item Estimated Cost(Dollars)to be official Use.Only
completed by ermit applicant
1. Building (a)"Building Permit Fee
2. Electrical (b)Estimated_Total'Cost_of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3+4+ 5) Q O U Check Number
This<Section,For Official Use°Onl
Building Permit Number: Date Issued:
i
Signature:
Building Commissioner/Inspector of Buildings Date
.2LMORTH MAIN ST BP-2005-0192
GIS#: COMMONWEALTH OF MASSACHUSETTS
k: 17C-254 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:roofmg BUILDING PERMIT
Permit# BP-2005-0192
Project# JS-2005-0223
Est. Cost: $32000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DOUGLAS B LUCE 136057
Lot Size(sg.ft.): 28488.24 Owner: SHEA TIMOTHY E TRUSTEE
Zoning:URB Applicant: DOUGLAS LUCE
AT. 21 NORTH MAIN ST
Applicant Address: Phone: Insurance:
122 AUDUBON RD (413) 584-8786
LEEDSMA01053 ISSUED ON:8116104 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 8/16/04 0:00:00 142 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo